The sensory system and

pain syndromes

Vth year, dentistry, 30.09.2008

Department of Neurology
Semmelweis University
 Sensory system
Receptors:
- specialised (smell, vision, hearing, taste
- visceral (viscera, smooth muscle -
unconscious or autonomic)
- somatic (skin, striated muscle, joints)
 Cutaneous
receptors

Muscle, tendon
receptors
 The sensory system
Spinothalamic system (tractus spinothalamicus)
exteroceptive sensation) :pain
temperature
light touch
Dorsal column pathway ( lemniscus medialis)
“conscious” proprioception: joint position
vibration
deep pressure
two point discrimination

graphaesthesia ! stereoaesthesia !
Dorsal and ventral spinocerebellar pathway
“unconscious” proprioception
 Pain

Nociceptors:
-Unimodal: mechanoreceptors, thinly myelinated fiber
-Bimodal: cold + mechanoreceptors, thinly myelinated and unmyelinated fibers
warm+mechanoreceptors
-Polymodal:warm-mechano-chemical receptors, unmyelinated fibers
 Spinothalamic system

Pain perception
C fibers: thin, unmyelinated
A delta: thinly myelinated

Temperature
A delta: thinly myelinated
 origin of pain - manifestations

Neuropathic pain Nociceptiv pain

Mixed
primary lesion or dysfunction caused by tissue damage
of CNS (peripheral or central)1 (bones,joints, tendons, muscles,
skin, viscera)2

Peripheral:
• Postherpetic neuralgia • Low back pain with • inflammation
• Trigeminal neuralgia radiculopathy • fractures
• Polyneuropathy in diabetes mell. • Cervical pain with • osteoarthritis.
• Posttraumatic neuropathy radiculopathy • Postoperativ visceral pain
Central: • Cancer pain
• Poststroke pain • Carpal tunnel Description:2
syndrome • smarting
Description:2 • Sharp
• Burning • Pulsating, throbbing
• Tickling, itching,pins and needles
• Hypersensitivity to touch/cold

1. International Association for the Study of Pain. IASP Pain Terminology.

2. Raja et al. in Wall PD, Melzack R (Eds). Textbook of pain. 4th Ed. 1999.;11-57
 Dorsal column pathway/
lemniscus medialis

Proprioceptiv modalities:
pressure,
vibration,
joint position
two points discrimination,

graphaesthesia !
stereoaesthesia !

Type of fibers: thick, myelinated

fibers (Aα, I, II)
Somatotopia in the cortex
Segmental innervation (dermatomes)
Peripheral innervation
 Sensory disturbances
Positive symptoms:
• Pain
• Hyperaesthesia:increased sensitivity to any stimulus
• Hyperalgesia: increased sensitivity to a painful
stimulus
• Hyperpathia: increased sensitivity with increasing
pain threshold to repetitive stimulation
• Paraesthesia:“pins and needles sensation”,
“burning feeling”
• Dysaesthesia: inappropriate sensation to a stimulus
• Allodynia: pain provoked by a non-painful stimulus
 Sensory disturbances

Negative symptoms:

• Hypoalgesia: reduced sensitivity to a painful

stimulus
• Hypoesthesia: reduced sensitivity to any
stimulus
• Analgesia: absent sensitivity to a painful
stimulus
• Anaesthesia: absent sensitivity to any stimulus
 Examination of the sensory system 1.
Special standpoints:
• “Subjective “ examination
• Requires good cooperation on the patient`s side.
• Allows accurate localisation of the pathology.
• Preliminary diagnosis is needed. Examine according to the
expected damage !
• Most often we compare different parts of the body.
• Do not tell the patient what should be felt !
• The patient should not see the examined part of the body !
• “Subjective” sensory disturbance ( pain, paraesthesia ) is not
necessarily accompanied by “objective” sensory disturbance
(hypaesthesia, anaesthesia )
 Examination of the sensory system 2.
Pain: pin prick, tooth picks
Light touch: use a wisp of cotton wool !
Temperature:use cold (5-10 0C)/or hot (40-45 0C) test tubes !
-Instruct the patient to reply: “Tell me if you feel the stimulus !
Name the area stimulated !” “Is it equal on both sides?
-Map out the extent of abnormality by moving from the
abnormal to the normal area (“Tell me if sensation changes!”)
Joint position / motion:
-Hold the sides of the patient’s finger ! Move it up and down at
random ! Ask to specify the direction of movement !
Vibration:
-Place a vibrating tuning fork on a bony prominence ( ankle,
knee, processus spinosus, processus styloideus radii et
ulnae, elbow, clavicula)
 Examination of the sensory system 3.
• Two point discrimination:
-The ability to discriminate two blunt points when applied
simultaneously. (3-5 mm on the finger, 4-7 cm on the trunk)

• Sensory inattention (perceptual rivalry)

-The ability to detect sensory stimuli applied simultaneously
on both limbs.
-Subdominant parietal lobe, associative areas

• Stereoaesthesia
- An object is placed in the patient’s hand.
- Ask patient to describe its size, shape, surface, material !
- Stereoanaesthesia:disturbance of the sensory afferent tracts.
 Examination of the sensory system 4.
• Astereognosis.
-Inability to identify an object by palpation
-The primary sense data being intact
-Lesion of the opposite hemisphere, postcentral gyrus
• Tactile agnosia :
-The patient is unable to recognize an object by touch in both
hands
-Disorder of perception of symbols.
-Lesion of the dominant parietal lobe, associative areas
• Graphaesthesia
- The ability to recognize numbers or letters traced out
on the palm.
Examination of the sensory system

• Nerve conduction studies:

sensory antidrom neurography
median nerve, ulnar nerve

• Somatosensory evoked potentials (SEP)

median nerve, tibial nerve
Peripheral nerve, Polyneuropathies
Peripheral nerve: according to the
distribution area of the affected nerve

Polyneuropathies: symmetrical
sensory disturbance in stocking/glove
like distribution, more pronounced
distally
Sensory disturbance usually starts on
the toes, gradually spreads higher,
rarely above the knee; later on the
hands
 Spinal ganglion

segmental, localised to dermatomes

 Root damage

• Sensory disturbance and

pain according to the
C7 dermatome (variability!)
• Anaesthesia does not
develop because of
overlapping dermatomes
S1
 Syringomyelia

• spinothalamic fibers crossing at cervical level are affected first

• dissociated sensory loss: temperature, pain disturbance on both hands
 Cranial structures - pain
• skull
• cervical spine
• eyes
• ears
• nose, sinuses
• teeth
• temporomandibular joint
 Headache
Pathways

PAG:periaqueductal gray matter

LC: locus ceruleus
TG:trigeminal ganglion
DRG:dorsal root ganglion
 Taking a headache history
• Age of onset ?
• Duration of complaint ?
• Time pattern
Continuous or transient ? Frequency and duration of
each headache ?
• Site ?
• Intensity, quality ?
• Associated phenomena ?
• Aggravating and relieving factors ?
Headache - duration - frequency
 Headache - „danger signals”
„Danger signals”:
• sudden onset of new, severe headache
• onset of headache after exertion, straining, coughing or sexual activity
• progressively worsening headache
• any abnormality on neurological examination
• systemic features: fever, arthralgia
• onset of first headache after the age of 50 years
Refer to specialist:
• Cooperating patient – ineffective treatment
• Chronic daily headache – drug abuse, dependency
• Severe anxiety , depression
• Severe comorbid diseases
 International classification of
headache disorders
Primary headaches: Secondary headaches:
1. Migraine 5. Posttraumatic (head/neck trauma)
2. Tension-type headache 6. Vascular disorder (cranial/cervical)
3. Cluster headache and other 7. Non vascular intracranial disorder
trigeminal autonomic headaches 8. Substance abuse/ withdrawal
4. Other primary headaches 9. Infection
10 Disorder of homeostasis
11.Disorder of facial/cranial structures
12.psychiatric disorder
Cranial neuralgias, central and primary facial pain :
13.Cranial neuralgias and central causes of facial pain
14.Other headache
International Headache Society. ICHD-II. Cephalalgia 2004; vol 24: suppl 1.
Migraine without aura A) n 5

B) 4 - 72 h

C) 1.
2.
2/4
3. ++ / +++

4.  /

D) 1. + 
1/2
2.

E) normal
Phases of migraine

Blau, Lancet, 1992

Migraine and „spreading depression”

Woods et al. 1994

Trigemino - vascular system

Lancet Neurology 2002;1:251-257.

 migraine - treatment
•Acute:
- Non specific: analgesics, NSAID, antiemetics
- Specific: ergotamine, dihydroergotamine, triptans

•Preventive (prophylactic):
- Episodic: if there is a trigger for a limited time ( menses)

- Chronic: decrease the frequency independently of triggers

Migrén gyógyszeres kezelésének protokollja,

Magyar Fejfájás Társaság, 2003
Tension type headache: criteria
A. n > 10

B. 30 min < duration of pain< 7 nap

C.

2/4

+ / ++

D.

2/2 /

E. normal
Convergence and sensitisation in the trigeminal nuclei
Thalamus
DRN, LC

pia / dura
vessels

art.
temp.

Trigeminus
nucleus
masticatory caudalis
muscle
Brainstem and
spinal cord
Tension type headache - treatment
Acute treatment: analgesics
NSAID
+ antiemetics, coffein

Preventive treatment: tricyclic AD

SSRI
valproat (?)

Complex treatment:pharmacological treatment

psychotherapy
relaxation
physiotherapiy (Not massage!)
Cluster headache: criteria
A) n 5

B) +++

30-180 min

C) 1/4

D) Frequency = 1/2 ->50

E) normal
 Cluster headache: treatment
Acute treatment: oxygen (7 l/min, 10 perc)
sumatriptan sc. inj.
ergotamine
indomethacin supp.
Preventive treatment: verapamil (360 mg/day)
valproate (600-1500 mg /day)

infiltration of occipital nerve ?

methysergide, pizotifen ?
lithium (chronic cluster!)

corticosteroids/dihydroergotamine
Surgical ?
 International classification of
headache disorders
Primary headaches: Secondary headaches:
1. Migraine 5. Posttraumatic (head/neck trauma)
2. Tension-type headache 6. Vascular disorder (cranial/cervical)
3. Cluster headache and other 7. Non vascular intracranial disorder
trigeminal autonomic headaches 8. Substance abuse/ withdrawal
4. Other primary headaches 9. Infection
10 Disorder of homeostasis
11.Disorder of facial/cranial structures
12.psychiatric disorder
Cranial neuralgias, central and primary facial pain :
13.Cranial neuralgias and central causes of facial pain
14.Other headache
International Headache Society. ICHD-II. Cephalalgia 2004; vol 24: suppl 1.
 Trigeminal neuralgia
V/1

V/2

V/1

V/1
V/3

V/3

C2/3
 Trigeminal neuralgia
• Prevalence: 10-20 / 100 000 population
• female/male : 1.6
• age of onset: > 50 years (90%)
• site: most frequently V/2,3
< 5 % V/1 division
~ 10 % all the three division
~ 5 % bilateral
Features:
• placebo effect 0 -1 % !
• trigger zone 90 %
• refracter phase
• spontanous remission ~ 50 %, < 6 months
• „pretrigeminal neuralgia”
 Trigeminal neuralgia
Classical/Idiopathic
• duration < 2 minutes
• affecting one/more divisions
• sudden onset
• severe, sharp,stabbing pain
• precipitated from trigger areas
• patiens is pain free between
paroxysm
• no neurological deficit
• no causative lesion
Symptomatic
• pain as described before
•persistence of aching
between paroxysm
• sensory impairment or other
neurological deficit
•causative lesion , other than
vascular compression
 Trigeminal neuralgia

mouth -ear zone, 60% nose - orbit zone, 30 %

 Peripheral aetiology -central pathogenesis
chronic irritation of trigeminal nerve division

focal demyelinisation

ectopic action potentials decrease of segmental inhibition

paroxysmal discharge of LTM interneurons of nucleus oralis n.V

paroxysmal discharge of WDR neurons of nucleus caudalis n.V

attack of trigeminal neuralgia

sites of trigeminal nerve damage
 Trigeminal neuralgia
• differential diagnosis
• examinations:anamnesis physical examination Rtg
otology dental surgery ophthalmology
brain MR trigeminal SEP psychology
„diagnostic blockade”
 Trigeminal neuralgia
• If it is possible determine causative lesion, treat it

• Pharmacological treatment
- antiepileptics
- muscle relaxants
- tranquillants

• TENS?

• surgery
Trigeminal neuralgia-pharmacological treatment
• Carbamazepine 400-1200 mg/day
• Phenytoin 300-600 mg/day
• Valproate 500-2000 mg/day
• L baclofen 40-80 mg/day
• Clonazepam 2-8 mg/day
• Pimozide 4-12 mg/day
• Tiapridal 300-600 mg/day
• Gabapentin up to 3600 mg/day
• Pregabalin ?
 Trigeminal neuralgia - phamacological treatment

• start with small dose, increase gradually

• prefer combination
• blood counts, hepatic, renal function tests are needed
• monitoring of complaints is important
• timing of discontinuation (after pain free for 8 weeks)
• gradual tapering is necessary
• 30 % of patients fail to respont to medical therapy
 Trigeminal neuralgia – surgical management
• Peripheral nerve blockade
• Percutanous radiofrequency trigeminal thermocoagulation
(Sweet, Wespic, 1974)
• Retrogasserian Glycerol injection (Hakansson, 1981)
• Radiosurgery - gamma knife
• Microvascular decompression (Gardner 1966, Janetta 1967,
MéreiFT 1973) Janetta: 85 % vascular compression a. cerebelli superior
V/2,3 a. cerebelli inferior anterior V/1 pain free : 80%,
mortality: 0.5 %
 neuralgias
Glossopharyngeal neuralgia: classical/symptomatic
- pain in the tonque, tonsillar fossa, angle of the jaw, ear
- peritonsillar abscess, oropharyngeal carcinoma !
Nervus intermedius neuralgia
- posterior wall of the auditory canal
- herpes zoster oticus !
Superior laryngeal neuralgia
Nasociliary neuralgia
Supraorbital neuralgia
Occipital neuralgia
- greater or lesser occipital nerves
- cervical spine !
 Central causes of facial pain
• Anaesthesia dolorosa:
- lesion of the relevant nerve/ after trauma (surgical?)
- diminished sensation to pin prick over the affected area(hypalgesia)
- spontaneous, persistent pain and dysaesthesia (allodynia)

• Central post stroke pain

• Persistent idiopathic (atypical) facial pain

- persisting pain without features of neuralgia
- on a limited area of the face, poorly localised
- no sensory deficit, investigations exclude relevant abnormality
 Chronic postherpetic neuralgia
• herpes zoster: trigeminal ggl. 15 % (V/1 80%)
ggl. Geniculi (VII, Ramsay-Hunt)
• pain > 3 months
• indicence: <40years:5 %, >60years:50 %, >70years:75 %
• lymphoma patients with lymphoma: 10-25 %
• treatment: capsaicin cream, vincristin iontoforesis
amitryptilin
carbamazepine,
valproat neuroleptics
amantadin
gabapentin
• prognosis: 56 % remission > 3 years
 Symptomatic headaches
• Giant cell arteritis
- incidence 3-9 / 100 000, 133 / 100 000(>50 years), 843 / 100 000 (>80 years)
- headache (70-90 %): permanent or transient, unilateral or bilateral
- swollen tender scalp artery, decreased pulsation (60 %)
- blindness (50 % -13 %): amaurosis fugax, AION transient / permanent
- diplopia (15 %)
- jaw claudication (25- 40 %)
- polymyalgia rheumatica (25 %)
- neurological signs: stroke, hearing loss, myelopathy, neuropathy
- elevated ESR and/or CRP (41 % > 100 mm/h, 89 % > 31 mm/h) biopsy
- treatment: 60- 80 mg methylprednisolon ( gradually decrease in every third day,
to 30 mg, then decrease weekly with 5 mg to 10 mg) 3 months, We ?
- headache relief within 3 days after the start of steroid treatment
• Costen syndroma